Patent Ductus Arteriosus - management in preterm infants
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15 minute lecture about the What, Why and How questions on PDA management of preterm infants in the NICU. Held at the Berzelius Symposium "The Cardiac Patient from Birth to Adulthood", 22 February 2019, Stockholm, Sweden.
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Patent Ductus Arteriosus - management in preterm infants
- 1. Patent Ductus Arteriosus - management in preterm infants Stefan Johansson consultant neonatologist, Sachs Children’s Hospital associate professor, Karolinska institutet Stockholm, Sweden The Cardiac Patient from Birth to Adulthood. Berzelius Symposium, 22 February 2019
- 2. ebneo.org
- 3. ”Despite…research and clinical experience… over 6 decades, there is still uncertainty and controversy about the significance, evaluation, and management of patent ductus arteriosus in preterm infants…” AAP Committee on Fetus and Newborn. Pediatrics Dec 2015. doi: 10.1542/peds.2015-3730
- 4. You will still be confused after this lecture
- 5. • What? • Why? • How?
- 7. Left-right-shunt through PDA leads to: • Hyperperfusion of the lung circulation • Hypoperfusion of the systemic circulation (brain, guts, kidneys etc) • Risk of heart failure (increased volume load on left side)
- 8. PDA – common clinical problem 0 20 40 60 80 100 22 w 23 w 24 w 25 w 26 w PDA rate (%) EXPRESS Group. Acta Paediatrica 2010;99:978.
- 9. PDA – how is it defined? van Overmeire. New Engl J Med 2000;343:674 • diastolic flow easily detectable… main pulmonary artery • diastolic backflow in the aorta immediately beneath the ductus • LA-to-Ao-ratio >1.6 Richards. Pediatrics 2009;124:e287 • left to right ductal shunting • increased LA-to-Ao-ratio • failure to wean from mechanical ventilation Gudmundsdottir. Neonatology 2015:107:87 • PDA defined as the ICD code for PDA Aikio. J Matern Fetal Neonatal Med. 2014;27:1252-6 • left-atrium-to-aorta ratio >1.3 • tachycardia • high systolic – diastolic BP difference • persistent respiratory distress
- 10. This ”disease” has no universal definition… Zonnenberg. Acta Paediatrica 2012;101:247
- 11. How to assess the PDA in the NICU?
- 12. • What? • Why? • How?
- 13. Closing the PDA is easy… … but what’s the point?
- 14. ”PDA increase the risk of…” • mechanical ventilation • pulmonary haemorrhage • NEC • IVH / PVL • ROP • BPD Are these associations true? • Conflicting results… • Treatment does not seem to reduce risks…
- 15. Causality or co-occurence? PDA BPD Preterm birth PDA BPD
- 16. Prophylactic Tx closes the duct but… 999 ELBW infants 49% had PDA after placebo21% had PDA after indo Schmidt. J Pediatr 2006;148:730 41% developed BPD45% developed BPD
- 17. Timing of medical closure and BPD risk Medical treatment (postnatal age) BPD (36 wks) 0-2 days 1.00 (ref) 3-6 days 0.83 (0.42-1.64) ≥7 days 0.28 (0.13-0.61) Background and results: • is long PDA shunt duration negative? • is later medical closure associated with higher BPD risk? Finding and interpretation: • timing of PDA treatment did not influence BPD risk Gudmundsdottir. Neonatology 2015;107:87-92
- 18. • What? • Why? • How?
- 19. Treatment options • Ibuprofen or indomethacin • Paracetamol • Surgery • Time (watchful waiting) Find details here: • Cochrane Database Syst Rev. 2015 Feb 18;(2):CD003481 • Cochrane Database Syst Rev. 2013 Mar 28;(3):CD003951 • Mitra. JAMA. 2018;319(12):1221-1238 • Jasani. Semin Perinatol. 2018;42(4):243-252 • Weisz. JAMA Pediatr. 2017;171(5):443-449 • Koch. Pediatrics. 2006;117(4):1113-21
- 20. Most interesting question – is ”treatment” always needed?
- 21. BeNeDuctus trial is recruiting! Primary (composite) outcome: • death, NEC, BPD Secondary outcomes • hypotension (inotropes) • duration of breathing support • brain lesions (IVH/PVL) • long-term development Hundscheid. BMC Pediatr. 2018 Aug 4;18(1):262
- 22. BabyOSCAR trial is recruiting! • 730 infants at 23-28 weeks (now 413 recruited) • Significant PDA within 72h: oibuprofen oplacebo • Primary (composite) outcome is death/BPD 36w • Secondary outcomes: oNEC, IVH, PVL, ROP, pulmonary bleeds orescue PDA tx; PDA surgery olength of respiratory support https://www.npeu.ox.ac.uk/baby-oscar
- 23. Are you still confused?
- 24. Conclusions • There is no universal PDA definition but… use echocardiography to set your diagnosis • You can always close the PDA but… noone knows exactly why you should • ”More research is needed”